A 52-year-old man comes to the physician because of increasing fatigue over the last 2 weeks. He has also been experiencing exertional dyspnea and occasional headaches. Cardiac auscultation findings at the left sternal border are shown below. Which of the following is most consistent with this patient's auscultatory findings?

Question

A 52-year-old man comes to the physician because of increasing fatigue over the last 2 weeks.  He has also been experiencing exertional dyspnea and occasional headaches.  Cardiac auscultation findings at the left sternal border are shown below.  Which of the following is most consistent with this patient's auscultatory findings?

Quizplus · Accepted Answer

11ec160b_3a7a_082c_9249_69c41fa5dbd9_MD0001_00 This patient has an aortic regurgitation (AR) murmur. It is a high-pitched, blowing, diastolic murmur; the intensity is maximal right after A2 (sound of aortic valve closure) and proceeds in a decrescendo pattern for part or all of diastole. Higher overall intensity and longer duration of the murmur correlate with the severity of AR, and A2 may be absent in severe AR. When AR is due to aortic root dilation (eg, in Marfan syndrome) the murmur is best heard at the right upper sternal border (classic aortic valve auscultatory location). However, for AR due to valvular pathology (eg, bicuspid aortic valve, rheumatic heart disease) the murmur is best heard at the left third intercostal space. In either scenario, the murmur is best appreciated at the end of expiration with the patient leaning forward (minimized lung volume with the heart closer to the chest wall enhances left-sided murmurs). (Choice B) Hypertrophic cardiomyopathy causes left ventricular outflow obstruction and produces a crescendo-decrescendo systolic murmur similar to that of aortic stenosis. The murmurs can be differentiated by maneuvers that increase left ventricular blood volume (eg, squatting); the murmur of hypertrophic cardiomyopathy decreases in intensity with increased left ventricular blood volume (outflow obstruction is reduced), whereas the murmur of aortic stenosis increases in intensity. (Choice C) Mitral valve prolapse is classically associated with a midsystolic click and a late systolic murmur best heard at the cardiac apex. (Choice D) Papillary muscle dysfunction can lead to mitral regurgitation, which causes a holosystolic murmur best heard at the cardiac apex. (Choice E) Tricuspid regurgitation causes a holosystolic murmur that is best heard at the left lower sternal border. The murmur can be differentiated from that of mitral regurgitation by auscultation during inspiration; the murmur of tricuspid regurgitation will increase in intensity with inspiration as right ventricular blood volume is increased. Educational objective: Aortic regurgitation (AR) causes a high-pitched, blowing, diastolic murmur with a decrescendo intensity pattern. The murmur of AR due to aortic root dilation is best heard at the right upper sternal border, whereas the murmur of AR due to valvular pathology is best heard at the left third intercostal space.

A 52-Year-Old Man Comes to the Physician Because of Increasing